NCLEX qquestions

Answers and Rationale of Questions

1. Answer: 1. Blood pressure decreases as the body is unable to maintain normal oncotic pressure with liver failure, so patients with liver failure require close blood pressure monitoring. Increased capillary permeability, abnormal peripheral vasodilation, and excess rennin released from the kidney’s aren’t direct ramifications of liver failure.

2. Answer: 2. Good circulation causes tissues to be moist and red, so a healthy, well-healed stoma appears red and moist.

3. Answer: 1. A colostomy in the sigmoid colon produces a solid, formed stool.

4. Answer: 4. High-fiber foods stimulate peristalsis, and a result, flatus. Yogurt reduces gas formation.

5. Answer: 2. A proper fit protects the skin, but doesn’t impair circulation. A 1/16” should be cut.

6. Answer: 2. Observation, auscultation, percussion, palpation

7. Answer: 4. An ileoanal reservoir is created in two stages. The two surgeries are about 2 to 3 months apart. First, diseased intestines are removed and a temporary loop ileostomy is created. Second, the loop ileostomy is closed and stool goes to the reservoir and out through the anus.

8. Answer: 3. The large intestine absorbs large amounts of water so the initial output from the ileostomy may be as much as 1500 to 2000 ml/24 hours. Gradually, the small intestine absorbs more fluid and the output decreases.

9. Answer: 2. To avoid overloading the small intestine, encourage the patient to eat six small, regularly spaced meals.

10. Answer: 2. Making observations about what you see or hear is a useful therapeutic technique. This way, you acknowledge that you are interested in what the patient is saying and feeling.

11. C After a Billroth II procedure, a large amount of hypertonic fluid enters the intestine. This causes extracellular fluid to move rapidly into the bowel, reducing circulating blood volume and producing vasomotor symptoms. Vasomotor symptoms produced by dumping syndrome include dizziness and sweating, tachycardia, syncope, pallor, and palpitations.

12. A Gastric emptying time can be delayed by omitting fluids from your patient’s meal. A diet low in carbs and high in fat & protein is recommended to treat dumping syndrome.

13. B Ascites puts pressure on the diaphragm. Paracentesis is done to remove fluid and reducing pressure on the diaphragm. The goal is to improve the patient’s breathing. The others are signs of cirrhosis that aren’t relieved by paracentesis.

14. A A full bladder can interfere with paracentesis and be punctured inadvertently.

15. B Cover the organs with a sterile, nonadherent dressing moistened with normal saline. Do this to prevent infection and to keep the organs from drying out.

16. A Asterixis is an early neurologic sign of hepatic encephalopathy elicited by asking the patient to hold her arms stretched out. Asterixis is present if the hands rapidly extend and flex.

17. A You may administer the laxative lactulose to reduce ammonia levels in the colon.

18. A Achalasia is characterized by incomplete relaxation of the LES, dilation of the lower esophagus, and a lack of esophageal peristalsis. Because nitrates relax the lower esophageal sphincter, expect to give Isordil orally or sublingually.

19. C Eating in the upright position aids in emptying the esophagus. Doing the opposite of the other three also may be helpful.

20. C Pancreatitis involves activation of pancreatic enzymes, such as amylase and lipase. These levels are elevated in a patient with acute pancreatitis.

21. D The normal range of specific gravity of urine is 1.010 to 1.025; a value of 1.030 may be seen with dehydration.

22. C Teach the pt to avoid activities that increase intra-abdominal pressure such as coughing, sneezing, or straining with a bowel movement.

23. C Because obesity weakens the abdominal muscles, advise weight loss for the patient who has had a hernia repair.

24. B After a liver biopsy, the patient is placed on the right side to compress the liver and to reduce the risk of bleeding or bile leakage.

25. A Signs and Symptoms of pneumothorax include dyspnea and decreased or absent breath sounds over the affected lung (right lung).

26. A An NG tube is inserted into the patients stomach to drain fluid and gas.

27. A Aspirating the stomach contents confirms correct placement. If an X-ray is ordered, it should be done immediately, not in 24 hours.

28. B TPN is given I.V. to provide all the nutrients your patient needs. TPN isn’t a tube feeding nor is it a liquid dietary supplement.

29. A Type A causes changes in parietal cells.

30. B Increasing fluids helps empty the stomach. A high carb diet isn’t restricted and fat intake shouldn’t be increased.

31. A Diarrhea d/t an acute episode of ulcerative colitis leads to fluid & electrolyte losses so fluid replacement takes priority.

32. D Sigmoidoscopy allows direct observation of the colon mucosa for changes, and if needed, biopsy.

33. C She needs a high-fiber diet and a psyllium (bulk laxative) to promote normal soft stools.

34. B Stools from ulcerative colitis are often bloody and contain mucus.

35. D One sign of acute diverticulitis is crampy lower left quadrant pain. A low-grade fever is another common sign.

36. C With acute pancreatitis, you need to rest the GI tract by TPN as nutritional support.

37. A The gallbladder is located in the RUQ and a frequent sign of gallstones is pain radiating to the shoulder.

38. D A Jackson-Pratt drain promotes wound healing by allowing fluid to escape from the wound.

39. D After creation of a colostomy, expect to see a stoma that is pink, slightly edematous, with some oozing. Bright red blood, regardless of amount, indicates bleeding and should be reported to the doctor.

40. A Only a small amount of skin should be exposed and more than 1/16” of skin allows the excretement to irritate the skin.

41. B Measuring abdominal girth provides quantitative information about increases or decreases in the amount of distention.

42. C Because the GI tract is functioning, feeding methods involve the enteral route which bypasses the mouth but allows for a major portion of the GI tract to be used.

43. B The first step in assessing the abdomen is to observe its shape and contour, then auscultate, palpate, and then percuss.

44. B Lowering the height decreases the amount of flow, allowing him to tolerate more fluid.

45. D Pancrelipase provides the exocrine pancreatic enzyme necessary for proper protein, fat, and carb digestion. With increased fat digestion and absorption, stools become less frequent and normal in appearance.

46. B Glucose level increases and diabetes mellitus may result d/t the pancreatic damage to the islets of langerhans.

47. D After surgery, she remains NPO until peristaltic activity returns. This decreases the risk for abdominal distention and obstruction.

48. D A brownish-black color indicates lack of blood flow, and maybe necrosis.

49. A Restricting fluids decrease the amount of body fluid and the accumulation of fluid in the peritoneal space.

50. D Dark green, leafy vegetables are rich in calcium.

51. A For pruritus, care should include tepid sponge baths and use of emollient creams and lotions.

52. D Rest periods and small frequent meals is indicated during the acute phase of hepatitis B.

53. D Hepatitis B can recur. Patients who have had hepatitis are permanently barred from donating blood. Alcohol is metabolized by the liver and should be avoided by those who have or had hepatitis B.

54. A To prevent venous stasis and improve muscle tone, circulation, and respiratory function, encourage her to move after surgery.

55. A Telling her not to worry minimizes her feelings.

56. A Diazepam is absorbed by the plastic I.V. tubing and should be given in the port closest to the vein.

57. A For the first few days to a week, slight bleeding normally occurs when the stoma is touched because the surgical site is still new. She should report profuse bleeding immediately.

58. D To wash away tissue debris and drainage effectively, irrigate the wound until the solution becomes clear or all the solution is used.

59. A Ammonia levels increase d/t improper shunting of blood, causing ammonia to enter systemic circulation, which carries it to the brain.

60. D Saline solution is isotonic, or close to body fluids in content, and is used along with sterile dressings to cover an eviscerated wound and keep it moist.

61. B Crohn’s disease penetrates the mucosa of the colon through all layers and destroys the colon in patches, which creates a cobblestone appearance.

62. A Stomach pain is often a late sign of stomach cancer; outcomes are particularly poor when the cancer reaches that point. Surgery, chemotherapy, and radiation have minimal positive effects. TPN may enhance the growth of the cancer.

63. C Melena is the passage of dark, tarry stools that contain a large amount of digested blood. It occurs with bleeding from the upper GI tract.

64. A A patient with an acute upper GI hemorrhage must be treated for hypovolemia and hemorrhagic shock. You as a nurse can’t diagnose the problem. Controlling the bleeding may require surgery or intensive medical treatment.

65. D To stabilize a patient with acute bleeding, NS or LR solution is given I.V. until BP rises and urine output returns to 30ml/hr.

66. A Initially, you should assess the patient’s knowledge about colostomies and how it will affect his lifestyle.

67. B An inflammatory condition that affects the surface of the colon, ulcerative colitis causes friability and erosions with bleeding. Patients with ulcerative colitis are at increased risk for bowel perforation, toxic megacolon, hemorrhage, cancer, and other anorectal and systemic complications.

68. C Medications to control inflammation such as corticosteroids are used for long-term treatment.

69. A Meats and beans are high-protein foods. In liver failure, the liver is unable to metabolize protein adequately, causing protein by-products to build up in the body rather than be excreted.

70. B A gastric residual greater than 2 hours worth of feeding or 100-150ml is considered too high. The feeding should be stopped; NG tube clamped, and then allow time for the stomach to empty before additional feeding is added.

71. C Frequent mouth care helps relieve dry mouth.

72. C Coffee-ground emesis occurs when there is upper GI bleeding that has undergone gastric digestion. For blood to appear as coffee-ground emesis, it would have to be digested for approximately 2 hours.

73. C Normally, drainage is bloody for the first 24 hours after a partial gastrectomy; then it changes to brown-tinged and then to yellow or clear.

74. D If the vagus nerve is cut as it enters the stomach, gastric acid secretion is decreased, but intestinal motility is also decreased and gastric emptying is delayed. Because gastric acids are decreased, gastric pH increases.

75. A Dosage problem. It’s 80/20 = 240/X. X=60.

76. A The output from an Ileostomy is described.

77. B As healing occurs from the bile duct, bile drains from the tube; the amount of bile should decrease. Teach the patient to expect dark green drainage and to notify the doctor if drainage stops.

78. C Misoprostol restores prostaglandins that protect the stomach from NSAIDS, which diminish the prostaglandins.

79. C

80. D

Read Questions here